9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PhysicalTherapyFallPrevention
SellsIndianHealthServiceHospital
Sells,Arizona,UnitedStates
HospitalCommunity

Aim:Todecreaseoutpatientfallsby50%in12months
ProcessData
Date:02/20/2014
Step

Description

Outpatiententersfacility

FailureMode

Causes

Effects

Adminstaffatfrontdesk
cannotdeterminefallrisk

Noassessmenttoolor
educationforclericaland
adminsitrativestaff

Nofallriskassignedto
patients

Step

Description

Patientfillsoutoutomemeasuresforspecificreferralproblem

FailureMode

Causes

Noinfotakenfrompatient
Notoolforriskassessment
specificallyregardingfallrisk forpatientspresentingwith
gaitdeviceissueonly.

Effects
Patientsreferredforcanes
gounassessedforfallrisk

Step

Description

Patientsitsinwaitingroomandwaitstobecalledinbythereapistfor
evaluationandtreatments

Step

Description

Patiententersclinicaltreatmentarea

FailureMode

Causes

Noassessmentoffallrisk
duringevaluation

Failureofstafftousean
Patientsatriskforfallgo
approipriateriskassessment unassessed
tool

Step

Description

Patientleavestreatmentarea

FailureMode

Causes

Patientnotidentifiedasafall Nofallrisktoolemployed
risk

Effects

Effects
Highriskoffallathomeorin
theclinic

Occ Det Sev RPN Actions

5

10

200 Initiatescreeningtooltoall
patientscomingfor
ambulationdeviceswithout
orderforphysicaltherapy
balanceprogram

Occ Det Sev RPN Actions

10

10

100 AnypatientreferredtoPT
forcaneorcrutchissuewill
filloutabriefquestionnaire
detailingiftheyhavehad
fallsinthelastyearandif
so,howmanyandwhatwas
theinjurythewysustained.
yesanswerswillprompt
messagetoprimarycare
doctor

Occ Det Sev RPN Actions

4

10

360 Allpatientswithoutpatient
Diagnosisofdifficulty
walkingorweaknessget
screenedwithabalance
assessmenttoolsuchasthe
Tinetti,BergbalanceorGet
upandgotool.

Occ Det Sev RPN Actions

10

10

500 Allpatientwhoareatriskfor
fallbyvirtueoftheirrisk
factorspresentandthe
reasonforreferralget
screenedbyatherapist.
Patientsreferredforissueof
gaitdevicegetscreenedby
administrativestaffwith
questionnaiirethatalertsPT
toco

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1160

Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=16974&ScenarioId=19191&Type=2

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